If this dosage of Sotalol is maintaining a normal rhythm, and this is confirmed with monitoring, no intervention is required at present. However, the likelihood of recurrence is quite high and when this occurs, ablation should be strongly considered. Ablation of typical Atrial flutter is a relatively low risk procedure with a very high incidence of true cure.
It should also be recognized that many patients with Atrial flutter are at risk for the development of Atrial fibrillation sometime in the future. So even if Atrial flutter is successfully treated long term monitoring for Atrial arrhythmias is still required.
I would agree that if your medicine is currently maintaining a normal rhythm, and you tolerate the drugs without difficulty, then there is no compelling indication for an ablation at the present time. At some point the medication will become ineffective and the frequency of your episodes of fibrillation will increase. Then an ablation will be the right form of therapy. Advantage of waiting until the drugs fail are further improvement in the techniques and experience in catheter based therapy.
The answers to your questions are difficult without some additional information as to the details of your ablative procedures and the need for a pacemaker. However, if the events are in fact debilitating and you have failed multiple attempts at medical therapy and ablation, then AV Node ablation with you existing pacemaker is a very good alternative.
As you know the procedure has changed dramatically over the past few years. We are currently performing 400-500 procedures a year and I have been involved in more than 2500.
As you may know, Atrial fibrillation is not uncommon in endurance athletes and may be related to the high resting Vagal tone. (Same thing that contributes to a low resting heart rate and blood pressure). The aim of your therapy should be to allow you to return to a normal lifestyle as best as possible so periodic Cardioversions and restrictions on exercise are not the answer.
Digoxin can be problematic in patients with paroxysmal Atrial fibrillation because though it is good for rate control, it has some real pro-arrhythmic potential in the atrium (make it more likely for AF to occur). So, I would agree with the suggestion to replace Digoxin with another medication such as Sotalol at the present time. Ultimately, the answer will be in catheter ablation as the only effective means of maintaining a normal lifestyle and normal rhythm without long term drug treatment. You may be a very good candidate for this intervention.
If at the present time your episodes occur only once a year, convert on their own, and can be helped by dietary changes, then it may be a bit early for ablative therapy. Possibly some treatment with beta blockers or gastrointestinal medicines may further delay more frequent episodes. At some point, the frequency will increase and definitive intervention with ablation will be necessary, but they may be quite some time in the future. As I have said, there are advantages to waiting on catheter ablation until the time is right for you.
It sounds like you have tried and not had a good response to antiarrhythmic therapy. I believe that long term amiodarone is not a good option given the potential for toxicity and your history of recurrence on low dose therapy. You should have a careful conversation with your cardiologist on the risks and benefits of ablative therapy as this may be your best option at present.
I believe that it is fair to say that “robotics” in many forms (da Vinci, Stereotaxis, Hansen) may have a future in catheter based treatment of Atrial fibrillation. However, at the present time there is no evidence that it improves success or reduces complications. Much more experience is required.
There is currently an experimental trial with a Left Atrial Appendage Occlusion device called the “Watchman”. This is a small “screen” that is placed in the left atrial appendage through a non-surgical catheter based technique to prevent blood clot formation and embolization, the common cause of stroke in patients with AF. It is being investigated as an alternative to Coumadin and may be very helpful to patients in your situation. The long term results are not in, but preliminary experience is encouraging. The NYU Heart Rhythm Center and others are involved in the trial and can be contacted for further information.
Dr. Andrea Natale
Dr. Andrea Natale is a board certified electrophysiology expert and practices at executive medical director of the Texas Cardiac Arrhythmia Institute at St. David's Medical Center in Austin, Texas. Dr. Natale also is the Senior Medical Director at Pacific Atrial Fib and Arrhythmia Center in San Francisco. He visits MetroHealth in Cleveland, and Akron General, Ohio. He has pioneered a new circumferential ultrasound vein-ablation system to correct atrial fibrillation and performed the procedure on the world's first five patients. For further details Please visit :Link
Dr. Dhanunjaya Lakkireddy
Dr. Dhanunjaya Lakkireddy, MD, F.A.C.C, FHRS. is a board certified electrophysiology expert and practices at Mid-America Cardiology and The University of Kansas Hospital Clinics in Kansas City, KS, USA. He has several distinctions in clinical and research career to his credit and serves as an associate editor for Journal of Atrial Fibrillation.For further details Please visit :Link
Dr. Dhanunjay Lakkireddy, MD, F.A.C.C, FHRS, The Kansas City Heart Rhythm Institute (KCHRI), KS, USA.
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